Resilience: resistance factor for depressive symptomjpm_1463

The purpose was to explore influence of resilience on the willingness of African Americans aged 65 and over to seek mental health care for depressive symptoms. Specifically, the study examined relationships between personal resilience and willingness of undiagnosed, community dwelling older adults to seek mental health care for depressive symptoms. A cross-sectional, correlational, causal modelling design was used to study older African Americans (N = 158; 121 women and 37 men) recruited from churches, retirement organizations and senior nutrition centres. Participants completed study instruments to measure depressive symptoms, resilience, willingness to seek mental health care, and general demographics information. Descriptive statistics and multiple regression analyses were preformed. Depressive symptoms and resilience accounted for 15.4% of the willingness to seek mental health care variance; extraction of resilience lowered variance to 0.9%. A direct, predictive relationship between resilience and willingness to seek mental health care was documented. Understanding resilience and willingness to seek mental health care supports future research for interventions that bolster resilience in older adults. Identifying the influence of resilience on such willingness may provide direction for developing interventions for older African Americans and may be applicable to vulnerable, marginalized and minority older adults worldwide. This study examined resilience, level of depressive symptoms, and the perceived level to which participants were willing to seek mental health care for those symptoms. Journal of Psychiatric and Mental Health Nursing, 2009, 16, 829–837 © 2009 Blackwell Publishing 829 Introduction and background Late-life depression is a global issue (Andreescu et al. 2008). Older African Americans are less likely than others in their age cohort to be diagnosed with or treated for depression (Gallo et al. 2005, Switzer et al. 2006). The exact prevalence of depression in older adults is unknown, because of non-diagnosis, misdiagnosis and under-treatment (Department of Health and Human Services 1999, Gallo et al. 2005). Overall estimates vary from 1% to 4% depending on severity or diagnoses (Blazer 2003). Older African Americans may subscribe to a cultural model of depression that forms a barrier to treatment seeking (Cooper et al. 2003, Switzer et al. 2006). This makes them less likely to accept antidepressant medications and more likely to use spiritual or religious approaches (prayer) (Cooper et al. 2003). The cultural model adopted by many older African Americans is shaped by beliefs that depression is an attitude, and therefore is one’s individual responsibility (Switzer et al. 2006). As such, one must take personal action to improve or change one’s attitude. Paradoxically, these beliefs may delay treatment seeking, but may shape fortitude and resilience. Advancements in health care enable many adults to lead rich, fulfilling lives in the midst of ongoing psychosocial losses (Department of Health and Human Services 1999, Smedley et al. 2003). Biological, psychological and social factors influence the development of depressive symptoms in later life (Blazer & Hybels 2005). Life stressors of older adulthood are linked to depressive symptoms and include medical co-morbidity, disability and decreasing social network (Blazer & Hybels 2005). Identified barriers to services utilization include trust, communication, insurance and ability to pay for prescribed medicines (Cooper et al. 2003, Thompson et al. 2004). Exploration of personal characteristics that form the cultural model within population subgroups may inform the development of interventions to enhance services utilization (Cooper et al. 2003, Ayalon & Alvidrez 2007). Research regarding depression management has proliferated in the past decade (Cohen et al. 2005a,b). These studies focus on treatment interventions and not on factors that motivate older adults to seek mental health care initially. Less abundant are studies exploring the relevant factors affecting the likelihood of seeking care for depression among symptomatic but undiagnosed older community dwelling African Americans. Studies of older groups of symptomatic Blacks show that mental health resource use varies with different demographics (Cohen et al. 2005a) even within the larger ethnic category (African American, African Caribbean, and African). Depression in minority populations is not limited to African Americans. A report of elder abuse (WHO/INPEA 2002) indicates that older adults in India describe ‘emotional problems, lack of emotional support, neglect by the family members, feelings of insecurity, loss of dignity, disrespect by the family’ (p. 9), which are associated with depressive symptoms. The report also describes older adult abandonment in hospitals in Kenya and Brazil, indicating reduced family support. African and African Caribbean immigrants are settled in countries other than just the United States (World Health Organization 2003), making their mental health utilization a global issue. Differences in the effect of race on syndromal and subsyndromal depression by racial group indicate financial strain as a statistically significant influence (Cohen et al. 2005b). Barriers to care commonly associated with minority and elderly populations (Department of Health and Human Services 1999) are poverty, including financial strain, and limited access to mental health facilities (Department of Health and Human Services 2002, National Center for Health Statistics 2005). Why some experiencing these barriers do not seek mental health care while others do, remains unclear. Studies of the association between depressive symptoms, resilience, and willingness to seek help among older adults, specifically African Americans, were not found in the literature. Factors that influence older African American’s willingness or reluctance to seek mental health care have been explored, but few studies examined resilience as an attribute affecting depressive symptoms (Edward 2005) and the willingness to seek treatment once symptoms occur. Therefore, this study explores the predictive impact of depressive symptoms and resilience on the willingness of older African American adults to seek health care for depressive symptoms. Specifically, this study seeks to determine relationships among depressive symptoms, resilience, and willingness to seek mental health care. Enhanced understanding of the relationships between sub-clinical depressive symptoms, resilience and services utilization supports the development of effective intervention strategies to improve mental health services utilization. Better understanding of the resilience characteristics that contribute to older African Americans’ willingness to seek mental health care for depressive symptoms could provide the basis for strategies to help improve and manage mental health care. Identified strategies may be applicable in marginalized population subgroups around the globe. Conceptual framework The conceptual framework for this study is built on the resilience model, the defining attributes of which apply P. R. Smith 830 © 2009 Blackwell Publishing along a continuum from vulnerability to survival using protective factors that enhance resilience (Werner & Smith 1992, Dyer & McGuinness 1996). The resilience model consists of a sense of carrying on, enduring values, problem-solving, appreciation for interaction with others, and comfort with some degree of aloneness (Werner & Smith 1992, Dyer & McGuinness 1996). Resilience is viewed as a protective factor that can be enhanced through intervention (Edward 2005). Resilience, ability to rebound, involves improvement in physical and psychosocial condition, and in recovery from an illness or loss (Felten 2000, Felten & Hall 2001). Exemplars are women whose actions demonstrate motivation, contributions to others’ lives, and improvements in their own lives through regular professional health care. Strengthening of coping skills, improving knowledge about affordable and available care, receipt of culturally competent and sensitive care, and encouragement to nurture and work with others also exemplify the concept of resilience (Felten 2000). Resilience involves personal coping qualities that help individuals survive and thrive despite adversity or misfortune (Connor & Davidson 2003) and encompasses hope for recovery, sense of self, determination, and pro-social attitudes and behaviours (Dyer & McGuinness 1996). Resilience is modifiable, suggesting that the tendency to develop desirable or undesirable outcomes (depressive symptoms) is alterable within the individual’s maturation and environment, or as a result of pharmacological treatment, specifically for persons experiencing post-traumatic stress disorder (Vaishnavi et al. 2007), and therefore, is an important component of behavioural health adjustments and outcomes. Psychosocial problems associated with experiences of racial discrimination, socio-economic disadvantage and financial strain affect the coping ability of older adults (Cohen et al. 2005a,b). Stressful psychosocial experiences including the legacy of slavery, the civil rights struggles and unjust restriction to the margins of society, influence the mental health and well-being of older African Americans (Mills & Edwards 2002). Coping ability and adjustment to stressful psychosocial events contribute to personal resilience, and highlight the need for greater understanding of the mental health of older adults, the in-depth exploration of which was beyond the scope of this study. The guiding framework incorporates selected concepts: depressive symptoms, resilience, and the willingness of older African American to seek mental health care. In this framework, the level of depressive symptoms predicts resilience which, then, predicts willingness to seek mental health care. Level of depressive symptoms is viewed to negatively affect resilience (Felten & Hall 2001). Resilience is viewed as a protective factor that can influence a person’s likelihood to avoid depressive symptoms (Aroian & Norris 2000, Edward 2005, Edward & Warelow 2005). This framework suggests that resilience may prevent depressive symptoms, or lessen the impact. If symptoms do appear, they may be less likely to ‘take hold’ or ‘cause problems’. Higher levels of depressive symptoms are expected to predict lower levels of resilience (see Fig. 1). The path from resilience to willingness to seek mental health care for depressive symptoms is predicted as positive (Felten & Hall 2001) and is based on the view that resilience is adaptive and evolving (Glantz & Johnson 2002, Rolf & Johnson 2002). These complex relationships reflect normal changes of ageing but do not include the mental problems that affect the health status, disability status and suicide rate of older adults.